The dawn to dusk fast in the Islamic month of Ramadan is obligatory for all Muslims. During fasting, Muslims abstain from food, drink whilst going about their normal daily activities. Poor understanding and appreciation of the practices by the medical professional may lead to compromise in treatment and inability to provide good service for the patients. This article provides insight to dentists around the globe to carry out comprehensive and preventive dental treatment to fasting patients in the month of Ramadan.

Ramadan is the 9 th month of the Islamic calendar (Hijra). Fasting is obligatory for all adult Muslims all over the world during the daylight hours. Since Hijra is a lunar calendar of about 350 days a year, Ramadan occurs at different times in a 33-year cycle. Fasting during Ramadan is total abstention from food, fluid during the daylight hours. [1] Therefore, it is important for healthcare professionals to know about their patients' cultural and religious rituals, which are obligatory. Certainly, with respect to their patients, this understanding is likely to result in increased satisfaction in the delivery of care. Patients will feel that their beliefs have been taken into consideration, and health professionals will be able to deliver care that their patients find acceptable and appropriate. [2]

Fasting during Ramadan is obligatory for all Muslims, with certain exemptions such as pre-pubertal children, ill person, women during menstruation, pregnancy, post-childbirth rest and lactation, travelers, and the frail elderly person. [1] However, some persons because of certain tradition and beliefs or due to personal reasons who have the right to be excused from fasting may observe the fast. [1],[2],[3]

Therefore, it is important that healthcare professionals are aware of how fasting can affect routine treatment, and also how the treatment plan can be modified to patients' benefit. [Table 1] shows a brief idea of general prescribing pattern for Muslim patient during Ramadan.

Table 1: General principles of prescribing during the fast of ramadan[5]

A fasting patient is not able to take medication by the oral route. If a person becomes ill within the period of a fast, however, it is allowable to break the fast. It is for the patient to judge the degree of illness, and if the illness is 'harmful' or life-threatening, they are advised to undergo treatment; because under Islamic law, preservation of life has the greatest priority.

Information in the dental literature on the implications of prescribing during the month of Ramadan is scarce. In a study [4] which reviewed the drug regimens of 81 Muslim patients during Ramadan found that drug dosage pattern was changed in about 46% patients while fasting. This included mainly missing doses, altered timing of doses, or taking heavy single dose at one time. In some cases, this irregular medication and improper dosage can at times have serious consequences. A larger dose taken once daily may have toxic side-effects, especially in the children and in the elderly. Therefore, dentists must be aware of possible non-compliance, and make allowances to accommodate the religious practices of their patients by making some modifications in medicine prescriptions. [3],[4],[5]

Simple solutions

Instead of penicillin V, which requires four doses daily, amoxycillin could be prescribed, which requires only three doses a day. The three doses may be rotated, thereby allowing the patient to take the medication outside the hours of fasting

Prescribe slow-release formulations of medication.

An example is the long-acting version of the non-steroidal, anti-inflammatory drug diclofenac (SR 75 mg): Only two doses are required per day.

Injections

Local anesthetics

This is an acceptable form of treatment for a fasting patient; [4],[5],[6] however, the dentist should be aware that some Muslim patients may be reluctant to undergo it. According to Islamic fatwa's by scholar's, administration of local anesthetics for dental treatment does not invalidate the fast.

Intramuscular and intravenous injections

Intramuscular and intravenous injections are generally allowed. [4],[5],[6] Examples that may be of particular importance to dentists are the insulin injections for diabetics and antibiotics given by the intramuscular or intravenous routes. However, the use of IV fluids for nutrition is prohibited while fasting as it energizes the fasting patient. [4]

Mouthwashes

Chlorhexidine is a commonly prescribed antiseptic mouthwash. It may be used as a mouthwash, spray, or gel for a variety of conditions.

Allowance is made for these, and others commonly prescribed in dentistry, to be used if required. However, patients may be reluctant to use any mouthwash for fear of absorption from the mucosa and of inadvertently swallowing some.

It may be advisable to discuss these issues with the patient concerned and to suggest that, if the patient is reluctant to use the mouthwash during the fasting period, he or she should use it outside fasting hours. [4],[5]

Topical Fluoride Applications

Fluoride application is often used for prevention of dental caries and also as a treatment for tooth sensitivity; in either case, the fasting patient may be reluctant to accept this treatment, the concern being that he or she could inadvertently swallow the varnish or paste. Dentists should thus recommend that adjunctive treatment is carried out outside the hours of fasting. [4],[5]

Pulp Capping Medicaments

The pulp capping medicaments such as calcium hydroxide, ledermix, iodoform pastes etc., are placed directly into the canal, or on to the pulp, and are often used in the treatment of acute pulpitis. This is allowed during fasting and does not invalidate the fast. [5]

Alvogyl

Localized placement of Alvogyl or a similar substance, often used in the treatment of dry socket, is acceptable during Ramadan. [5]

Topical Gels and Lozenges

Intra-oral gels and lozenges are mainly prescribed for ulcers, oral thrush, and denture stomatitis. If this is applied during the fasting hours, it will invalidate the fast. Therefore, use of these medications will be poor in fasting patients. So, it is recommended to schedule these medications after fasting hours. [4],[5]

Almost without exception, these conditions will necessitate administration of medication immediately (e.g. adrenaline injection in the case of anaphylaxis), or immediately after the initial event has taken place (e.g. diazepam injection in the case of prolonged epileptic seizures). Islamic rules governing fasting are very clear; one of the acceptable reasons for breaking the fast is if life is threatened. Thus, if a person has a condition that is a threat to his or her life (perhaps he or she has poorly controlled diabetes), it is forbidden by Islamic law for them to continue fasting. [6],[7],[8],[9]

Treatment of Children

Before the age of puberty, Muslims are not obliged to fast. Therefore, prescribing and offering treatment for this age group should not differ from the norm. However, treatment of children above this age will follow patterns similar to those mentioned for adults. [3],[5],[7]

Oral Hygiene

Toothpastes are allowed. [3],[4],[5],[6],[7],[8] Some scholars of Islam consider the use of toothpaste to be highly undesirable because deliberate or accidental swallowing of them will nullify the fast. [7] The use of miswaak, the twig of Salvadora persica tree, is highly recommended, including the fasting period. miswaak is commonly used in Arab countries, and studies show that it is equally effective as other modes of oral hygiene maintenance. [8] The dental surgeons and the health care givers should remind the fasting patients to brush and floss thoroughly before sleeping at night and recommend brushing after the pre-dawn meal (sahur/sehri). Brushing twice daily is sufficient for oral disease prevention. [5],[6]

Oral malodor and fasting

During fasting, the salivation decreases and mouth becomes dry resulting in halitosis. [5] The increase in the concentration of sulfur-containing compounds causes a marked halitosis, which may be misdiagnosed for oral diseases or poor oral hygiene. The odor may reduce with proper oral hygiene debridement with dentifrices or when the individual breaks the fast. [1],[6],[7],[9]

Conclusion

Some Muslims patients may wrongly perceive that some dental treatments and preventive procedures invalidate the fast even though most dental treatment will not break the fast. This includes scaling, restorations, and extractions. However, some patients may not be willing to carry out certain procedures due to different perceptions and way of thinking. Within the month of Ramadan, most forms of prescribing are allowable, with the notable exception of oral medication. Even with acceptable types of medication, the dentist will often find open or hidden reluctance to comply with the regimen prescribed. The healthcare professional must be aware of this and should alter their prescribing practice or advice accordingly. It is also important, when treating a fasting patient on long-term medication, to ensure satisfactory compliance with the normal drug therapy. With fasting patient in dental practice, it is important for professionals to be aware of which treatments the individual considers acceptable and offer treatment accordingly.